Nail psoriasis: clinical features, pathogenesis ... · of the distal phalanx turns red and develops some pustules migrating under the nail and causing nail dystrophy. With time, the
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http://dx.doi.org/10.2147/PTT.S126281
Nail psoriasis: clinical features, pathogenesis, differential diagnoses, and management
Eckart Haneke1–4
1Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland; 2Dermatology Practice Dermaticum, Freiburg, Germany; 3Centro de Dermatología Epidermis, Instituto CUF, Porto, Portugal; 4Department of Dermatology, University Hospital, Gent, Belgium
Abstract: Psoriasis is the skin disease that most frequently affects the nails. Depending on
the very nail structure involved, different clinical nail alterations can be observed. Irritation
of the apical matrix results in psoriatic pits, mid-matrix involvement may cause leukonychia,
whole matrix affection may lead to red lunulae or severe nail dystrophy, nail bed involvement
may cause salmon spots, subungual hyperkeratosis, and splinter hemorrhages, and psoriasis of
the distal nail bed and hyponychium causes onycholysis whereas that of the proximal nail fold
causes psoriatic paronychia. The more extensive the involvement, the more severe is the nail
destruction. Pustular psoriasis may be seen as yellow spots under the nail or, in case of acroder-
matitis continua suppurativa, as an insidious progressive loss of the nail organ. Nail psoriasis
has a severe impact on quality of life and may interfere with professional and other activities.
Management includes patient counseling, avoidance of stress and strain to the nail apparatus,
and different types of treatment. Topical therapy may be tried but is rarely sufficiently efficient.
Perilesional injections with corticosteroids and methotrexate are often beneficial but may be
painful and cannot be applied to many nails. All systemic treatments clearing widespread skin
lesions usually also clear the nail lesions. Recently, biologicals were introduced into nail psoriasis
treatment and found to be very effective. However, their use is restricted to severe cases due to
high cost and potential systemic adverse effects.
Keywords: nail psoriasis, etiology, pathology, quality of life, impact, treatment
IntroductionPsoriasis is a chronic inflammatory disease with a strong genetic background but highly
influenced by environmental factors. Its prevalence is ~1–2% of the world population
with considerable differences among regions and individuals with different skin types.
It is the skin disease that most frequently affects the nail. At the time of consultation,
roughly one half of the patients suffer from nail changes. Over lifetime, up to 90% of
all psoriatics will have had nail alterations. The prevalence of nail psoriasis is even
higher in psoriatic arthritis.1 Nail lesions often appear around 10 years later than
skin lesions, which may in part be the reason for nail psoriasis being observed less
frequently in children. In general, cutaneous psoriasis is more severe in individuals
with nail involvement.
Etiology and pathogenesisNeither gender nor race predilection appears to exist. There is no association of HLA-
C0602 with nail and joint involvement, but nail psoriasis is often associated with an
inflammation at the insertion points of tendons and ligaments giving rise to enthesitis.
Journal name: Psoriasis: Targets and TherapyArticle Designation: REVIEWYear: 2017Volume: 7Running head verso: HanekeRunning head recto: Nail psoriasisDOI: http://dx.doi.org/10.2147/PTT.S126281
Onychomycosis is said to be the most frequent nail dis-
ease. It has many features in common with nail psoriasis,
both clinically and histopathologically (Table 1).1
Another important differential diagnosis is the asym-
metric gait nail unit syndrome seen mainly in the big toenail
as an onycholysis without further criteria of nail psoriasis or
onychomycosis.9 Furthermore, nonspecific nail dystrophy,
particularly of toenails, is very common in the elderly, in
subjects with peripheral arterial disease, chronic venous
stasis, after trauma to the leg, in peripheral neuropathy, and
in some dermatoses such as eczema, nail lichen planus,
Darier’s disease, Hailey-Hailey disease, alopecia areata, and
many drugs.1,8
Table 1 Differential diagnosis of nail psoriasis and onychomycosis
Psoriasis Onychomycosis
Frequency High, commonest dermatosis with nail involvement Very high: up to 30–40% of all nail disordersCourse Chronic, often recurrent Chronic, often progressiveSymptoms Usually cosmetically and functionally embarrassing Embarrassing, sometimes painSigns Variable depending on nail structure involved Variable, depending on severity and type of onychomycosis as
well as pathogenic agentPits Very common, regular in size and shape Rare, irregularOnycholysis Common CommonDiscoloration None to yellow Yellow to brownSpores and hyphae Rarely spores Very frequentTransverse furrows Rare RareSkin lesions elsewhere Very common Often tinea pedum/manuumTrauma May be induced by Köbner phenomenon Important predisposing factorHeredity Strong hereditary component, particularly in juvenile
onset psoriasisAutosomal dominant susceptibility to develop onychomycosis
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Grading and assessment of nail psoriasisReliable repeatable specific validated severity and outcome
measures are necessary to evaluate a disease and its response
to a specific treatment.11 This was missing in nail psoriasis
until the nail psoriasis severity index (NAPSI), target NAPSI,
and its many variants were established.12 NAPSI is calculated
by dividing each nail into four quadrants. Each quadrant is
evaluated for the presence of psoriasis manifestations of
the nail matrix, such as pitting, leukonychia, red spots in
the lunula, and nail plate crumbling, as well as of the nail
bed, such as oil-drop phenomenon, onycholysis, subungual
hyperkeratosis, and splinter hemorrhages. If any of these
signs is present in all four quadrants, a score of 4 is given.
A score of 0 represents no signs in any quadrant. Each nail
is evaluated for a matrix and a nail bed score of 0–4. They
are combined to yield a maximal score of 0–8 for each nail.
All nails may be evaluated, with the total NAPSI score being
the sum of the scores, up to 80 if only fingers are considered,
or up to 160 if fingers plus toes are included.12 If only the
most seriously affected nail is evaluated, it is called target
NAPSI; this is often done to assess the effects of a therapeutic
regimen.11 Many therapeutic studies use (target) NAPSI-50,
NAPSI-75, and NAPSI-90 to indicate the percentage of
patients that reach a (target) NAPSI improvement of 50, 75,
or 90%, respectively. The NAPSI has some disadvantages,
such as being too time-consuming to be used in clinical
practice, and that the NAPSI scores often do not correspond
with the clinical severity of nail psoriasis.13 A new scoring
system, the N-NAIL, overcomes many of these limitations,
but it has yet to prove its clinical practicability.13 The use of
many different scoring systems, major differences in study
design, inclusion criteria, and follow-up make it difficult if
not impossible to compare the results of most nail psoriasis
trials.11 In addition, subjective and objective patient factors
such as quality of life, satisfaction with treatment ease and
outcome, adverse effects and not the least practicability, and
cost of treatment are important factors.11 Such an evalua-
tion and assessment tool for nail psoriasis has recently been
published under the term of nail assessment in psoriasis and
psoriatic arthritis.14
AssociationsPsoriasis is a frequent skin disease. In the last decades, a
metabolic syndrome associated with psoriasis has been
described; however, this is not of particular importance for
ungual psoriasis except in psoriatic arthritis. Associations
and co-occurrence with other skin disorders involving the
nail are rather common. The most important differential
diagnosis is onychomycosis. Both conditions may look very
similar. A psoriatic nail may be colonized with pathogenic
fungi, and a true infection of the psoriatic nail is not infre-
quent (Table 1).1,15
Impact on quality of lifeNail psoriasis has a profound negative influence on all aspects
of quality of life as well as on daily, sports, and professional
activities.16–20 Women try to hide their nails and cover them
with nail lacquer; although common nail varnishes are not
harmful, artificial nails, particularly when long, increase
the mechanical stress and strain to the nail plate – nail bed
attachment acting as a Köbner phenomenon and worsening
nail psoriasis. Similarly, professional activities with particu-
lar use of the fingers may have a deteriorating effect on the
disease. Matrix involvement scores higher than pure nail bed
affection as it results in more obvious nail plate damage.19
CourseNail psoriasis is chronic but often improves and worsens
without known reasons (Figures 1–4). Trauma may play an
important role in the exacerbation of nail psoriasis. There
may be periods without any nail alterations.1,8,10
Management of nail psoriasisManagement of the disease includes patient education,
avoidance of trauma to the nails, and different therapeutic
approaches with physical and pharmaceutical procedures
and agents.
Patient counseling includes education on the nature of
psoriasis, how life may be influenced by nail involvement,
about the specific problems of treatment, that nail psoriasis
is not due to an allergy or an “unhealthy” diet and thus is not
treatable with particular foods. However, smoking increases
the risk of psoriasis and obesity and alcohol use are associated
Figure 1 The thumbs of the patient mainly show nail bed involvement with subungual hyperkeratosis, salmon spot, and onycholysis.Notes: (A) Before treatment (September 2011). (B) After 3 months of topical treatment with calcipotriol plus betamethoasone dipropionate ointment and clobetasol solution under the nails: the right thumb shows some improvement and the left thum nail has worsened (December 2011).
hyperkeratosis, and onycholysis.25,26 All high-potency steroids
carry the risk of skin atrophy when used on the proximal nail
fold, often associated with hypopigmentation. Whether or
not using them for 4–5 days a week as a “pulse” treatment is
Figure 2 Further development of the nail psoriasis.Notes: (A) After continued topical treatment (March 2012). (B) After repeated perilesional injections of triamcinolone acetonide crystal suspension (10 mg/mL), a marked improvement is seen (June 2012).
Figure 3 As topical and injection treatments are insufficient and inconvenient, systemic methotrexate is instituted.Notes: (A) Further improvement of the left thumb nail after 2 months of methotrexate (September 2012). (B) Despite continuous methotrexate therapy, the left thumb nail worsened again (July 2013).
Figure 4 There is residual nail bed psoriasis under methotrexate therapy. Finally, a biological treatment is instituted.Notes: (A) Slight distal onycholysis and subungual hyperkeratosis (November 2013). (B) Six weeks after the beginning of adalimumab therapy, the patient has 20 clear nails for the first time since >25 years.
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betamethasone in addition. Whereas the results were com-
parably good, the Nd–YAG was significantly more painful.122
Photodynamic therapy (PDT) uses light and a photoactive
substance that both generate reactive oxygen species able
to kill those cells that accumulated the photosensitizer. In a
comparative study, no difference was found between PDL
and PDT.117 However, there is considerable heat develop-
ment during the illumination of the target and this is often
not tolerated by the patients.
ConclusionNail involvement in psoriasis is common. It is an indicator of
poor prognosis and of a higher risk to develop psoriatic arthritis.
Surprisingly, nail psoriasis is only briefly mentioned in most
national and European guidelines on the diagnosis and treat-
ment of psoriasis; however, the European Nail Society is now
working on recommendations for the treatment of nail psoriasis.
The many treatments available give evidence that hitherto
none is the ideal therapy. Topicals have to fight with the dif-
ficulties to get through the nail and nail fold to the diseased
structures. Injections that bring the remedy to the site of the
disease process and greatly avoid systemic effects are pain-
ful and carry the risk of local side effects. Systemic drugs
are often not used for isolated nail psoriasis, although this is
accepted as a severe psoriasis considerably impairing quality
of life. However, it is known that virtually all systemic treat-
ments that improve the skin lesions are also beneficial for
the nails, although often with a delayed and less pronounced
response. The potential systemic adverse effects have to be
kept in mind before and during such a therapy. The develop-
ment of new biologicals has revolutionized psoriasis treat-
ment and thus also that of ungual psoriasis. Finally, there
are some physical modalities such as ionizing rays, various
light qualities including photodynamic treatment, and lasers.
Many treatment possibilities may make it delicate to
choose the right approach. It is certainly wise to begin with
a topical antipsoriatic preparation (Table 2). This has to be
used for a minimum of 4–6 months before its efficacy can
be evaluated. If this does not help sufficiently, a classical
antipsoriatic drug such as methotrexate, fumaric acid ester,
and cyclosporine would be the second choice while keep-
ing in mind all potential contraindications. If the results are
not satisfying a biological may be chosen. Again, there are
many contraindications that have to be carefully looked for
before starting such a treatment. The choice is huge now, and
the treating physician has to select among TNF-a blockers,
agents interfering with T-lymphocyte functions, and IL-23
and IL-17 inhibitors.
In summary, nail psoriasis is still an underestimated part
of psoriasis, but the outlook is bright with many new treat-
ments available.
DisclosureThe author reports no conflicts of interest in this work.
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No improvement Systemic antipsoriatics (MTX, CyA [FAE])
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